Helping patients weigh their options

Illustration of people hanging pictures on the wall.

Health care providers need to be prepared to deal with issues and questions cancer patients may have regarding sexual health and fertility.

The St. Jude Fertility Clinic provides a safe place for conversations and interventions.

What’s one of the top 5 concerns for adolescent patients undergoing cancer therapy? If you said “fertility,” you’d be correct.

Infertility can be a distressing consequence of cancer treatment. It affects quality of life and can cause psychological distress. Many times, we’ve met with long-term cancer survivors who shed tears as they learned they likely no longer had the ability to have biological children.

Some adult survivors fear the rejection of their partners if they disclose they may be unable to have children and may choose to avoid revealing that fact to their partners. Fertility issues can also be a predictor of stress in relationships and can cause higher rates of divorce.

But it’s not just patients at high risk for infertility who may be affected. Those who perceive themselves to be infertile—even though they are not—are less likely to use contraception. Patients must know how their chemotherapeutic or therapeutic regimens will affect their fertility so they can make appropriate decisions. Because adolescents and young adults sometimes do not make good decisions, it’s important to arm them with that information up front.

As providers, we need to be prepared to deal with issues and questions these patients may have regarding sexual health and fertility.

A commitment to fertility preservation

St. Jude has made an institutional commitment to fertility preservation for our patients. This extends both to our active patients as well as to survivors who did not have the opportunity to bank eggs or sperm because they were too young at the time or, perhaps, didn’t have time to do so prior to therapy.

As part of that commitment, St. Jude will pay for the medications involved in fertility preservation, for the egg or sperm retrievals and the processing, as well for as the annual storage fees at the third-party company until the patients are age 35. That gives patients a fair amount of time to decide what they want to do with those materials. St. Jude does not, however, cover costs related to the eventual use of those samples and any related fertility treatments.

The St. Jude Fertility Clinic, a collaborative effort with Fertility Associates of Memphis, opened in 2014. In our clinic, we do fertility consults where we discuss the treatment-based risks to a patient’s fertility. This can occur before treatment and after treatment as well. Fertility Associates of Memphis provides semen analysis results and processes samples through their andrology lab. They also perform oocyte retrievals at their outside surgical center. In addition, they handle the processing, temporary storage and shipment of preserved biological materials to a third-party company.

The benefit of having patients come to the St. Jude Fertility Clinic is that if there are questions above and beyond their fertility risk, patients get answers. But it’s also a place where we can document those discussions, a place where patients can have discussions that are separate from those about their overall cancer treatment. Without the St. Jude Fertility Clinic, questions about fertility risks might easily get lost amid conversations about neutropenia, hair loss, hearing loss, and all the other side effects that may arise from therapy.

Post-therapy options

We see a lot of long-term survivors. With these individuals, we review their fertility risks based on the treatments they had, and we perform fertility evaluations.

Between 2014 and 2017, the St. Jude Fertility Clinic saw 292 patients who had malignant disease. Of the post-therapy patients, we saw a lot of abnormal evaluations. For example, 42 males who were post therapy had semen evaluations. Over half of those, 52.4%, had no sperm in their sample, and 26.2% had some reduced and/or abnormal semen analyses. Of the females, 63.7% had grossly abnormal evaluations, with 26.3% having some impaired fertility.

We do have fertility preservation services. We implore clinicians to send as many patients to us as they can before therapy begins. For women, the best measures we’ve had to assess fertility over time have been performing follicle counts and doing ultrasounds so that we can count how many follicles are in the ovaries. However, we now have a lab test that can also help in giving us a measure of the overall quantity and quality a girl or woman has.

A lot of patients do the preservation post-therapy. If we’re not able to do the preservation prior to their gonadotoxic therapy, we can try and do it afterward. Of course, there’s no guarantee. Also, there’s very little data about the quality of eggs and whether they will result in pregnancy for patients who have already had gonadotoxic therapies.

Even if we’re able to get eggs out, we discuss other options with patients, including donor oocytes, embryo adoption, gestational carriers and adoption. All of this is part of a fertility risk assessment for both males and females that encompasses multiple factors. Those assessments help us as we work with patients to determine what is right for them.

Don’t hesitate: have the conversation

The literature suggests that over half of oncologists may fail to discuss fertility risk with their patients. Because of the St. Jude Fertility Clinic, that’s not the case here, but it is a problem throughout the country.

Some oncologists do not make referrals because they lack proper training and knowledge. Some don’t refer because they perceive there’s not enough time to delay therapy. Other oncologists don’t think their patients are interested because the patients haven’t mentioned fertility preservation.

As we now know, this is a crucial conversation to have, because it can have long-term repercussions for survivors. As a result, we urge all oncologists to make appropriate referrals to reproductive endocrinologists.

About the Author

Kari Bjornard

Kari Bjornard, MD, MPH, is a former assistant member in the Cancer Survivorship Division of the Oncology Department at St. Jude Children's Research Hospital.